Ethical Framework for Resource Allocation in Times of Scarcity
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Ethical Framework for
Resource Allocation in
Times of Scarcity
Ju ne 2 0 20National Ethics Advisory Committee | Kāhui Matatika o te Motu
Citation: National Ethics Advisory Committee. 2020. Ethical Framework for Resource
Allocation in Times of Scarcity. Wellington: Ministry of Health.
Published in June 2020 for the National Ethics Advisory Committee – Kāhui Matatika
o te Motu by the Ministry of Health
PO Box 5013, Wellington 6140, New Zealand
ISBN: 978-XXXX (online)
HP XXXX
This publication is available on the National Ethics Advisory Committee website:
www.neac.health.govt.nzContents
National Ethics Advisory Committee – Kāhui Matatika o te Motu ..................................................................................................................................1
Members of NEAC ............................................................................................................................................................................................1
Members of the secretariat ...............................................................................................................................................................................1
Acknowledgements ..........................................................................................................................................................................................1
Introduction ..........................................................................................................................................................................................................................2
Key features of the COVID-19 virus .................................................................................................................................................................2
Te Tiriti o Waitangi ...........................................................................................................................................................................................2
A focus on equity ..............................................................................................................................................................................................3
Increasing risk through unequal distribution and exposure to the determinants of health ...........................................................................3
Indigenous health inequities in New Zealand ..............................................................................................................................................4
Human rights ..............................................................................................................................................................................................4
Ethical principles .................................................................................................................................................................................................................5
Introduction.......................................................................................................................................................................................................5
Tensions between the principles.................................................................................................................................................................5
Allocation of resources .....................................................................................................................................................................................................10
Resources ......................................................................................................................................................................................................10
Clinical resources .....................................................................................................................................................................................10
Public health resources ............................................................................................................................................................................11
Support service resources ........................................................................................................................................................................11
Making decisions ............................................................................................................................................................................................11
The decision-making process ...................................................................................................................................................................11
Establishing a decision-making group ......................................................................................................................................................12
General allocation guidance.............................................................................................................................................................................................13
Should COVID-19 patients be prioritised over patients without COVID-19 in resource allocation? ...........................................................13
How will resource allocation impact electives and routine health care? ....................................................................................................13
P a g e |iNational Ethics Advisory Committee | Kāhui Matatika o te Motu
Should the standard of care for patients change in an epidemic? .............................................................................................................14
How will data be collected and shared? ....................................................................................................................................................14
What are organisations’ obligations? ........................................................................................................................................................14
Example 1: Intensive care unit allocation .......................................................................................................................................................................15
Introduction.....................................................................................................................................................................................................15
Applying the principles ....................................................................................................................................................................................15
Prioritising the people most in need ..........................................................................................................................................................15
Getting the most out of resources .............................................................................................................................................................15
Achieving equity .......................................................................................................................................................................................16
All people are equally deserving of care ...................................................................................................................................................16
General considerations .............................................................................................................................................................................16
Example 2: Personal protective equipment allocation ..................................................................................................................................................20
Introduction.....................................................................................................................................................................................................20
Applying the principles ....................................................................................................................................................................................20
Prioritising the people most in need ..........................................................................................................................................................20
Getting the most from the resources .........................................................................................................................................................20
Achieving equity .......................................................................................................................................................................................21
All people are equally deserving of care ...................................................................................................................................................22
General considerations .............................................................................................................................................................................22
Example 3: Vaccine allocation .........................................................................................................................................................................................24
Introduction.....................................................................................................................................................................................................24
Applying the principles ....................................................................................................................................................................................24
Getting the most from the resources .........................................................................................................................................................24
Prioritising the people most in need ..........................................................................................................................................................24
Achieving equity .......................................................................................................................................................................................25
All people are equally deserving of care ...................................................................................................................................................25
General considerations .............................................................................................................................................................................25
Bibliography .......................................................................................................................................................................................................................27
P a g e | iiMembers of the secretariat
National Ethics Advisory
Nic Aagaard, Rob McHawk, Hayley Robertson, Martin Kennedy,
Committee – Kāhui Matthew Poulson, Tristan Katz.
Matatika o te Motu Acknowledgements
The National Ethics Advisory Committee – Kāhui Matatika o te Motu The ethical framework for making resource allocation decisions was
(NEAC) is an independent advisor to the Minister of Health (the Minister). developed by NEAC, with support and advice from Angela Ballantyne,
The members of NEAC are appointed by the Minister and bring expertise Kiri Dargaville, Cheree Shortland-Nuku and Helen Wihongi.
in ethics, health and disability research, health service provision and
leadership, public health, epidemiology, law, Māori health and consumer
advocacy.
NEAC published Getting Through Together: Ethical values for a
pandemic in 2007 (NEAC 2007). Ethical Framework for Resource
Allocation in Times of Scarcity builds on the work of Getting Through
Together.
Members of NEAC
Maureen Holdaway, Kahu McClintock, Wayne Miles, Neil Pickering, Liz
Richards, Hope Tupara, Dana Wensley, Gordon Jackman, Mary-Anne
Woodnorth.
P a g e |1National Ethics Advisory Committee | Kāhui Matatika o te Motu
close contact with an infectious person (including in the 48 hours
Introduction before that infectious person exhibits symptoms of their infection)
contact with droplets from an infected person’s cough or sneeze
As a result of COVID-19, we are experiencing an increasing demand on
our health care system and its resources. Clinical professionals and touching objects or surfaces (such as doorknobs or tables) that
public health officials are likely to have to make decisions about situations have droplets from an infected person and then touching your
they have never experienced before. This framework has been mouth or face (Australian Government Department of Health 2020).
developed to help clinicians, nurses, hospital administrators and public
COVID-19 is a new disease, so there is no existing population immunity.
health policy makers optimise distribution and prioritisation of vital
This means that COVID-19 can spread widely and quickly.
resources in times of scarcity.
Symptoms of COVID-19 can range from mild illness to acute respiratory
NEAC emphasises that the document is best used to identify important
distress syndrome (ARDS). Some people will recover easily, others may
ethical principles, highlight ethical tensions and support robust decision-
get very sick very quickly, and some will die.
making; it is not a set of rules and does not consider all potentially scarce
resources or all potential decisions.
Te Tiriti o Waitangi
NEAC note that this document is in response to the COVID-19 pandemic.
NEAC intend to develop this document to be more generally applicable Te Tiriti o Waitangi / the Treaty of Waitangi (Te Tiriti) is one of the major
to pandemics as part of their wider work program, which involves sources of New Zealand’s constitution. Te Tiriti creates a basis for civil
updating ‘Getting Through Together: Ethical values for a pandemic’. government encompassing all New Zealanders. The Government
continues to respond to its obligations to honour Te Tiriti. Te Tiriti
mandates that Māori participate in equal partnership with the
Key features of the COVID-19 virus Government. To this end, Māori must have protection and receive
The virus can spread from person to person through: acknowledgement of their rights and interests within their shared
citizenship.
P a g e |2The New Zealand health and disability system has a responsibility to Increasing risk through unequal distribution and
contribute to meeting the Crowns obligations under Te Tiriti. As an exposure to the determinants of health
independent advisor to the Minister, this ethical framework supports the
This framework recognises that every person is of equal moral worth.
New Zealand health and disability system in meeting its obligations under
However, significant health inequalities exist among different groups of
Te Tiriti by drawing on the principles of Te Tiriti as articulated by the
New Zealanders. This difference in health status between groups is
courts and the Waitangi Tribunal and considering their implications for
influenced by socioeconomic factors and compounded by structural
resource allocation decisions.
inequities, such as racism and discrimination. Structural inequities
Supporting the New Zealand health and disability system to meet its systematically disadvantage individuals and groups based on ethnicity
obligations under Te Tiriti is necessary if we are to ensure iwi, hapū, and social positioning (ie, age, gender, ability). This results in the unequal
whānau and Māori communities are active partners in preventing, distribution of power and resources and differentiated access and
mitigating and managing the impacts of a pandemic or public health exposure to the acknowledged determinants of health. Research
emergency on whānau, hapū, iwi and Māori communities (Ministry of persistently shows that Māori, Pacific peoples and people from lower
Health 2020). socioeconomic demographics experience worse health and die younger
than other New Zealanders (Ministry of Health 2020).
A focus on equity Disabled people are of equal value and have the same rights as all other
New Zealanders. Yet an underlying, pervasive and often unquestioned
Pandemics and other public health emergencies often have the biggest
devaluing of disabled people exists called ‘ableism’. When ableism
impact on marginalised communities. Pandemics highlight and
intersects with ageism and/or racism, it can compound discrimination and
exacerbate already existing inequities within the health system. For this
specific human rights violations, deprioritisation in access to resources
reason, NEAC provides ethical guidance and notes the importance of
and poorer-quality health services.
considering equity in resource allocation. Equity recognises that different
people with different levels of advantage require different approaches
Māori, Pacific peoples and disabled people, older people, people with
and resources to achieve equitable health outcomes.
intellectual and psychosocial impairments and those with chronic health
P a g e |3National Ethics Advisory Committee | Kāhui Matatika o te Motu
conditions, co-morbidities, dependence on ventilators and compromised the preamble of the Universal Declaration of Human Rights (United
immunity face are even more vulnerable during the COVID-19 pandemic. Nations 1948).1 Human dignity is the ultimate foundation of all human
rights and fundamental freedoms.
These factors are particularly relevant when allocating clinical resources
during a pandemic.
Indigenous health inequities in New Zealand
Māori experience higher rates of infectious diseases than other New
Zealanders (Ballantyne 2020). For COVID-19, older people and
individuals with underlying conditions are at increased risk of severe
infection. Māori as a population have higher rates of chronic conditions
and comorbidities and are therefore more likely to develop severe
COVID-19 as a result of contracting SARS-CoV-2 infection. In addition,
Māori often have more people living in their households, which places
more people at risk from exposure to infectious diseases – but
conversely, more people in the household stand to benefit from
preventative actions.
Human rights
This framework is underpinned by all people’s right to good health,
including access to necessary resources, as expressed in article 25 and
1 Article 25 reads: ‘Everyone has the right to a standard of living adequate for the health and well-being society …shall strive … by progressive measures, national and international, to secure their
of [themselves and their] family, including …medical care ... .’ And, in the declaration’s preamble universal and effective recognition.’
the General Assembly of the United Nations proclaims that: ‘... every individual and every organ of
P a g e |4For example, with COVID-19, it may not be possible to achieve equity
Ethical principles and to benefit the most people possible. As an example, in the case of
intensive care unit (ICU) beds or ventilators, the decision might be made
to treat those with fewer comorbidities first because this is predicted to
Introduction
be the best way of saving as many lives as possible. Yet, doing so may
This section sets out four resource allocation principles and four Te Tiriti undermine equity if some groups (such as Māori or disabled people) tend
principles (tables 1 and 2 respectively). to have more comorbidities than other groups to start with.
This framework does not prioritise the principles ethically or conceptually. From a theoretical position, NEAC’s approach fits with the idea that the
However, the two sets of principles do have one important common different and sometimes inconsistent values and principles of ethics are
ground: they highlight the important factors, particularly for Māori, that prima facie. This means that wherever they are relevant, they are
must be considered when allocating scarce resources. Importantly, the significant, but a particular value or principle may sometimes have to be
way they are applied will vary depending on the resource being sacrificed to realise another value or principle, judged of greater weight
considered, the level of scarcity and the context (clinical or public health). or significance in the circumstances. From a psychological standpoint,
people will often feel a variety of values pulling them in different
Tensions between the principles directions, experiencing internally the ethical dilemmas described later in
this framework around the three examples of intensive care unit
NEAC holds that having multiple principles reflecting a plurality of values
allocation, personal protective equipment allocation and vaccine
is the best basis of ethical decision-making. It may be that in some
allocation.
circumstances different principles can be followed at the same time. For
example, in some elective surgeries, prioritising those with most need
The three examples show the tensions that exist between values and
and achieving the most benefit might be considered in tandem to achieve
principles when making difficult decisions. NEAC believes that good
the best result. But in a pandemic (as with many other contexts), values
decision-making involves recognising, rather than ignoring, these
and principles can conflict.
tensions.
P a g e |5National Ethics Advisory Committee | Kāhui Matatika o te Motu
Table 1: Resource allocation principles
The resource allocation principles chosen reflect the important considerations that are made when prioritising scarce resources. They are in tension and
must be considered in light of each resource allocation decision.
Resource allocation principle Application to resource allocation
Each person affected by the COVID-19 pandemic in New Zealand deserves equal respect and consideration.
Resources should not be distributed arbitrarily or withheld on the basis of individual or group characteristics that
are irrelevant to the clinical prognosis, for example, including: ‘race, colour, sex, language, religion, political or
All people are equally
other opinion, national or social origin, property, birth or other status such as disability, age, marital and family
deserving of care
status, sexual orientation and gender identity, health status, place of residence, economic and social situation’
(United Nations Committee on Economic, Social and Cultural Rights. 2009).2 There must be sufficient evidence to
demonstrate that these factors are predictive of prognosis if they are to be used in allocation decisions.
Fair allocation should aim to avoid a first-come, first-served bias.
Resources required for the COVID-19 pandemic response must be managed responsibly. In the context of a
health emergency, we should aim to allocate resources efficiently and maximise the clinical benefits.
Getting the most from the There are several competing interpretations of how best to measure clinical benefit, for example: to maximise
resources lives saved, to maximise life years saved (eg, by prioritising the young to maximise length of lives saved), to
maximise the cost-effective use of resources and to prioritise essential workers (such as health care staff) so they
can continue to serve and protect the public.
2 Note also that under the New Zealand Health and Disability Commissioner (Code of Health and Disability Services Consumers' Rights) Regulations 1996, right 2, every health consumer has the right to be free from
discrimination. See: www.hdc.org.nz/your-rights/about-the-code/code-of-health-and-disability-services-consumers-rights/
P a g e |6Resource allocation principle Application to resource allocation
There are competing interpretations of how to measure need – the sickest, the most disadvantaged or
marginalised, those at greatest risk of harm or those subjected to previous injustices.
Prioritising the people most in Prioritising those in need will sometimes align with and sometimes conflict with prioritising those who can most
need benefit from health resources.
One option is to give priority to individuals or groups in greatest need in order to restore them to an appropriate
health threshold3
‘In Aotearoa New Zealand, people have differences in health that are not only avoidable but unfair and unjust.
Equity recognises different people with different levels of advantage require different approaches and resources
to get equitable health outcomes’ (Ministry of Health nd).
An equity approach would consider how resources can be allocated to mitigate the adverse consequences of
Achieving Equity pandemic response measures and avoid or minimise growth in inequity deriving from those measures.
It is likely to be difficult to ameliorate existing inequity during a public health crisis, however, all efforts must be
made to ensure equity is at the forefront of decision-making.
The COVID-19 pandemic shed light on existing social fault lines and provided momentum to address entrenched
inequity after the acute emergency had passed.
3 The World Health Organization stated in the Rio Political Declaration on Social Determinants of Health (WHO 2011) that people have the right to ‘the highest attainable standard of health’. The highest attainable
standard of health is a reflection of the standard of health enjoyed in the most socially advantaged group within a society. This indicates a level of health that is biologically attainable and the minimum standard for
what should be possible for everyone in that society. See Achieving Equity in Health Outcomes (Ministry of Health 2018) for more information.
P a g e |7National Ethics Advisory Committee | Kāhui Matatika o te Motu
Table 2: Te Tiriti o Waitangi principles
The principles of Te Tiriti o Waitangi, as articulated by the Courts and the Waitangi Tribunal, provide the framework for how our health and disability
system ought to meet its obligations under Te Tiriti in its day-to-day work. The Waitangi Tribunal’s 2019 Hauora report recommends a set of principles for
the primary health care system that are applicable to the wider health and disability system and are applied to resource allocation principles in table 2
below (Waitangi Tribunal 2019, pages 163–64).
Te Tiriti o Waitangi principles as set out in the Te Tiriti o Waitangi principles’ application to Te Tiriti o Waitangi principles’ application to resource
Hauora report the primary health care system allocation
The guarantee of tino rangatiratanga, which Tino rangatiratanga requires clinicians, In a resource allocation setting, this means that
provides for Māori self-determination and hospital administrators and public health Māori are key decision makers in the design,
mana motuhake in the design, delivery and policy makers to provide for Māori self- delivery, prioritisation and monitoring of health and
monitoring of primary health care. determination. disability services and the response to pandemics or
public health emergencies.
The principle of options, which requires the Options, which requires clinicians, hospital In a resource allocation setting, this means that the
Crown to provide for and properly resource administrators and public health policy health and disability system is agile in adapting and
kaupapa Māori primary health services. makers to provide for and properly resource responding to the pandemic resource needs of
Furthermore, the Crown is obliged to ensure kaupapa Māori health and disability services kaupapa Māori health and disability services to be
that all primary health care services are in response to a pandemic or public health able to serve Māori communities.
provided in a culturally appropriate way that emergency.
recognises and supports the expression of
hauora Māori models of care.
The principle of active protection, which Active protection, which requires clinicians, This requires the clinicians, hospital administrators
requires the Crown to act, to the fullest extent hospital administrators and public health and public health policy makers to prioritise
P a g e |8Te Tiriti o Waitangi principles as set out in the Te Tiriti o Waitangi principles’ application to Te Tiriti o Waitangi principles’ application to resource
Hauora report the primary health care system allocation
practicable, to achieve equitable health policy makers to act, to the fullest extent resources to actively protect the health of the Māori
outcomes for Māori. practicable, to protect Māori health and population and implement approaches to equip
achieve equitable health outcomes for Māori whānau, hapū, iwi and Māori communities with the
This includes ensuring that the Crown, its
in response to a pandemic or public health resources to undertake and respond to public health
agents and its Treaty partner are well
emergency. measures to prevent and/or manage the spread and
informed about the extent, and nature, of both
transmission of disease among their people.
Māori health outcomes and efforts to achieve
Māori health equity.
The principle of partnership, which requires Partnership, which requires the clinicians, In a resource allocation setting, this means that the
the Crown and Māori to work in partnership in hospital administrators and public health health and disability system works alongside Māori
the governance, design, delivery, and policy makers and Māori to work in leaders to enable a coordinated and united
monitoring of primary health services. Māori partnership in the governance, design, response to a pandemic or public health emergency
must be co-designers, with the Crown, of the delivery and monitoring of the response to a whereby Māori have the resources to govern,
primary health system for Māori. pandemic or public health emergency. This design, deliver, manage and monitor a response
contributes to a shared responsibility for and the impacts on Māori communities.
achieving health equity for Māori.
P a g e |9National Ethics Advisory Committee | Kāhui Matatika o te Motu
during a pandemic. Each resource has a different risk/benefit profile and
Allocation of resources may be rationed or prioritised using a different weighting of the principles,
for example, a clinical or medical context in the case of ventilators or a
public health context in the case of personal protective equipment.
Resources
When we don’t have enough of a particular resource to meet demand, Support services are an additional category of essential pandemic
we must decide the best way to distribute that supply of resource to resources and, if allocated well, they can be useful in mitigating risk for
individuals and communities.
ensure the most effective results. Resource allocation is the mechanism
we use to do this.
This framework could be applied to a variety of resources. Some options
This framework applies to extreme measures intended to be are listed below. 5
implemented only in the worst-case scenario, in which adequate
Clinical resources
resources are not available. The application of principles and the relative
weighting of different principles may differ between emergency and non- Treatment has burdens and benefits; the decision to allocate a clinical
emergency situations. For example, a novel COVID-19 vaccine would resource is complex and requires assessment of futility/appropriateness
still need to meet safety and efficacy standards; but it may be ethical to of medical intervention, the patient’s best interests, the patient’s
endorse a wide-spread immunisation programme without long-term autonomy and the principles of resource allocation. Clinical resources
outcome data.4 include access to:
Ethical resource allocation should not be limited to clinical resources. ICU
There are many different kinds of resources that may become scarce ventilators
4 For example, the New Zealand Health and Disability Commissioner (Code of Health and Disability 5The options listed expand on those discussed in Sydney Health Ethics: An Ethics Framework for
Services Consumers' Rights) Regulations 1996, right 4, states that every health consumer has the Making Resource Allocation Decisions within Clinical Care: Responding to COVID-19 (University of
right to services of an appropriate standard. (See: www.hdc.org.nz/your-rights/about-the- Sydney 2020).
code/code-of-health-and-disability-services-consumers-rights/) However, what is ‘appropriate’ will
be interpreted differently depending on context and the resources available.
P a g e | 10 palliative care health navigators
medications. health and disability advocates
rehabilitation support (given the growing evidence of disabilities
Public health resources
associated with critical COVID-19 e.g. Post-Intensive Care
These are clearly valuable goods, typically with minimal risks or Syndrome cases).
downsides. They include:
personal protective equipment (PPE) Making decisions
diagnostics
The decision-making process
clinical expertise
Good decision-making processes confer legitimacy on the final
vaccines. decisions, even when disagreement persists, and may help to resolve
ongoing disagreement. They may also help ensure that decisions include
Support service resources comprehensive consideration of relevant issues.
These are measures that can increase access to services and mitigate
Pandemic planning decisions should be clearly consistent and
adverse impact. They include:
underpinned by ethical values. A good decision-making process fosters
carers visitation rights (allocating PPE to support this) public trust and goodwill towards institutions such as hospitals, leading
accessible communication (public and patient) to greater acceptance and satisfaction and fewer complaints. Such
processes identify values recognised in Māori tikanga or kawa (protocol
supported decision-making tools and services
or ceremonial actions) alongside other values.
financial support for home careers
It has been suggested that ‘due process requirements are inherently
interpreters
important because fair hearings affirm the dignity of the person’ (Bayer
social workers 2007 p. 266). Good decision-making processes may be necessary in
P a g e | 11National Ethics Advisory Committee | Kāhui Matatika o te Motu
order to show respect for people and ensure procedural fairness. As frequently re-evaluate their allocation criteria since the application of
such, they may also reflect the value of tika, in the sense of acting in a ethical frameworks should be a fluid process that moves back and
way that is just and proper. Māori tikanga and mātauranga Māori may forth along a continuum contingent on available resources and as
need to be considered in the context of challenging other values not just the understanding of the spread, pathophysiology, treatment and
sitting alongside those values. outcomes of COVID-19 infection evolves
determine the best way of communicating clearly and consistently to
A wide range of views can be present when considering ethical issues,
appropriate personnel about when crisis level allocation or re-
and it is common to have a lack of consensus about which values and
allocation is and is not in effect
principles are the most important on which to base a decision. This is
another reason why we need to develop acceptable, fair processes. take into account Te Tiriti articles and principles and their
application to resource allocation
Establishing a decision-making group6
consider plans for ensuring staff safety, maintaining clinician-to-
NEAC recommends that a decision-making group be established in patient ratios, training additional personnel, supporting
appropriate health services institutions at both the national and local organisational resiliency and providing support resources for staff
level, as necessary. Each institution will need to consider the kind of (child care, payment, sick leave, etc.)
membership for their decision-making group that will work best for them.
ensure appropriate communication with patients, the local
Each group should include the perspectives of their particular institution’s
community and the broader general public about plans for scarce
patients, Māori, disabled people, clinicians, ethicists, legal and any other
resource allocation
relevant stakeholders who will be impacted by the decisions the group
maintain communication links between local and national
will be making. The group should:
responses.
6 The recommendations in this section are based on information from Ethical Framework and
Recommendations for COVID-19 Resources Allocation When Scarcity is Anticipated (University of
Virginia Health System Ethics Committee 2020)
P a g e | 12In the clinical context, a key aim is to separate care and advocacy for a an infected patient over any patient who is not infected (University of
particular patient from the allocation decisions. This provides a level of Sydney 2020).
detachment from the immediate clinical needs of each patient, better
ensuring a clear and defensible decision-making process around How will resource allocation impact electives and
resource allocation, thereby reducing the opportunities for accusations of routine health care?
bias. It also has the advantage of protecting those clinicians caring
If resources, such as clinical expertise, become scarce, it may be
directly for patients from some of the direct stress and anxiety of being
necessary to prioritise responding to the pandemic over non-essential
the decision-makers about allocation.
interventions (elective surgeries, cancer screening) that can be
postponed. However, such a decision could have significant health
In the public health context, establishing a group allows transparency and
impacts for individuals and should not be taken lightly. The decision is
clear communication between the national and local levels. It also
grounded in two interrelated justifications. The first is to reduce the
ensures a clearer path to engaging with local communities.
spread of COVID-19. The second is to prepare for a potential swell of
COVID-19 patients.
General allocation Postponing non-essential interventions necessarily involves a trade-off
between the harm caused by postponing routine care and the potential
guidance harm of health systems being overwhelmed. Decisions relating to
postponing non-essential interventions, need to be continually
Should COVID-19 patients be prioritised over patients reassessed. National instructions to prohibit non-essential services may
without COVID-19 in resource allocation? cause harm if they are applied to organisations in regions that do not
have a high risk of COVID. The decision-making group needs to make
NEAC agrees with Sydney Health Ethics: An Ethics Framework for
its decisions based on local and or regional data.
Making Resource Allocation Decisions within Clinical Care: Responding
to COVID-19 that there are no ethically defensible grounds to prioritise The group also needs to give explicit consideration to the implications of
tikanga and mātauranga Māori, including involving tikanga experts in the
P a g e | 13National Ethics Advisory Committee | Kāhui Matatika o te Motu
discussion, when making decisions about standards of care in times of How will data be collected and shared?
crisis.
Data sharing between different institutions is critical in effective resource
Should the standard of care for patients change in an allocation. For example, there may be opportunities for district health
epidemic? boards (DHBs) to share resources, depending on the extent of impact of
COVID-19 in each region. It will be important to ensure that adequate
Patients should receive the best available care during a pandemic.
care standards are in place to protect privacy and maintain confidential
However, the range of options for what is ‘best’ could well change as a
communications – crisis standards of care do not weaken the
result of the constraints imposed by a pandemic. For example, patients
fundamental obligation to protect the privacy and confidentiality of
may not be allowed to have visitors (especially when PPE is scarce). This
patients.
will be necessary to protect staff and other patients and reduce the risk
of transmission from and to visitors. Collecting high-quality ethnicity and disability data for monitoring is
fundamentally important. Data collection and sharing enables the
This could mean that some patients become seriously ill and die without
response measures and allocation decisions to be monitored and tailored
the usual support of relatives and friends. This will inevitably cause
to respond promptly and effectively to evidence of inequitable impacts
distress to all parties. Access to other modes of communication, such as
and outcomes.
phone and video calls, should be provided where possible. It is important
that all organisations inform the public about any changes to standards What are organisations’ obligations?
of care before such changes are introduced (University of Sydney 2020).
Organisations must share information, adjust protocols, and balance
Where patients who are not infected are discharged earlier because of resources and patient loads across their immediate surrounding region
the concerns of a pandemic, those patients should receive more to ensure as consistent a standard of care is maintained as possible.
extensive continuing care at home to ensure they are not disadvantaged Public health decisions should be transparent.
(University of Sydney 2020). This could be achieved through increased
telehealth services, and should only occur when clinically appropriate.
P a g e | 14appropriateness to take into account, which may limit the ability for equity
Example 1: Intensive care to be fully realised.
unit allocation Applying the principles
Introduction Prioritising the people most in need
In order to show fairness and sustain public trust, we need to implement Patients with the most severe disease who are most likely to die or suffer
triage guidelines consistently throughout New Zealand. Solidarity without treatment should be prioritised for ICU access. Often this
requires that resource allocation reflect our common interest in principle will align with getting the most out of resources because the
addressing any pandemic; collaborative regional cooperation may sickest patients will be most likely to benefit from ICU care. However,
require the reallocation of resources between health services based on some patients will fall below a threshold where they are so sick there is
differential need. Clear and consistent triage guidelines and triage minimal chance of their survival, even with ICU intervention.
committees can reduce the moral injury and distress frontline health
workers can experience during a pandemic.
Getting the most out of resources
Most critical care triage guidelines prioritise saving lives as the primary
Current approaches of guidelines for access to ventilators and ICU beds
ethical value, for example, resources should be allocated to patients with
use comorbid conditions, future life expectancy and health and public
the greatest capacity to benefit from ICU. This is often defined as the
safety workers’ status as the key determinants for prioritisation – all of
likelihood of surviving an ICU admission and for one year following
which disadvantage lower socioeconomic classes, Māori, Pacific peoples
discharge (Bideson 2018). This principle conflicts with the principle of
and people with disability.
achieving equity of clinical outcomes.
There are several tensions to be considered when allocating resources
Giving priority to individuals who have the most chance of benefiting from
in the clinical setting, as there is the additional consideration of clinical
treatment in ICU may achieve the aim of saving the maximum number of
lives. But greater ability to benefit is often associated with wider
P a g e | 15National Ethics Advisory Committee | Kāhui Matatika o te Motu
determinants of health, such as higher socioeconomic status. All people are equally deserving of care
Socioeconomic status in turn may be systematically distributed to some
Disability status or age must not be used as a simple proxy for health
groups and away from others. As a result, a socioeconomically
status or capacity to benefit. Screening measures, including the quality-
advantaged group may be more likely to be represented among those
adjusted life year (QALY) measure, must be avoided as they are
individuals selected for ICU. Where reduced ability to benefit by reason
inherently biased against people with disabilities. Triage decisions should
of socioeconomic disadvantage is linked to injustice, this results in a
be based on assessment of an individual’s personal medical history
tension with the value of equity.
(noting the tendency for medical records to be error-prone).
Achieving equity
General considerations
Given the unequal distribution of comorbidity and multi-morbidity
The following considerations have been adapted from Maves et al 2020.
amongst the New Zealand population (for example on the grounds of
socioeconomic depravation and ethnicity), it will be very difficult to avoid
When implemented, triage guidelines must be applied to all current and
unequal outcomes based on demographic factors.
new patients presenting with critical illness, regardless of the diagnosis
of COVID-19 or other illness.
For critically ill COVID-19 patients, the primary consideration should be
whether ICU care is in the patient’s best interest and what other care may
NEAC recommends an independent decision-making group be
be appropriate, including palliative or supportive care. When ICU space
established to enact a triage plan.
is severely limited, there will be tension between utility (saving the most
lives) and equity (ensuring fair outcomes between groups). This tension It is important to ensure that patients who do not initially receive critical
cannot be resolved via ethical analysis at the stage of admission to ICU, care resources are still provided with the best supportive care possible
as clinical considerations take precedent at that stage. and are re-evaluated regularly for consideration of resource allocation as
supplies become available.
P a g e | 16Patients who are unable to receive invasive mechanical ventilation may process and principles of right 7(4) in the Health and Disability
be able to receive supplemental oxygen through a non-invasive route as Commissioner (Code of Health and Disability Services Consumers'
resources permit. Rights) Regulations 1996.7 Care may also be ethically withdrawn if it is
judged to be medically inappropriate because the prospect of benefit falls
The implementation of early palliative care interventions can provide a
below a predetermined threshold.
better quality of life, less treatment intensity, and no consistent impact on
mortality (Maves et al 2020). This offers a strong rationale for carefully Depending on the demand for care within ICU, estimated length of stay
integrating symptom management alongside palliative care principles for per patient and epidemiological surge projections, hospitals may be
all patients who are impacted by crisis care. justified in keeping some ICU beds empty in order to be prepared to care
for subsequent high-priority patients.
There is no ethically significant difference between withholding and
withdrawing life-sustaining treatment; but health care providers, patients Health care should not be denied or limited based on quality of life
and families often find decisions to withdraw treatment more emotionally judgements (Maves et al 2020).
and psychologically challenging.
Time trials of ICU may be necessary to manage patients and families’
expectations and avoiding prolonged stays in ICU with minimal and
decreasing prospects of benefit. Clear criteria and schedules for re-
assessing patients on time trials will be necessary.
ICU care may be ethically withdrawn when it is no longer in the patient’s
best interests (harm of treatment now outweighs the prospect of any
benefit). Decisions about the patients’ best interests must follow the
7 See: www.hdc.org.nz/your-rights/about-the-code/code-of-health-and-disability-services-consumers-
rights/
P a g e | 17National Ethics Advisory Committee | Kāhui Matatika o te Motu
Table 3: Assessment of the impact of mechanisms suggested in literature to prioritise scarce resources against the resource allocation principles
All people are equally Getting the most from the Achieving equity (achieve ‘more’ Prioritising the people most in
Mechanisms
deserving of care resources (population health) equal outcomes) need
Clinical scoring + Assesses all patients by Will successfully maximise Will not achieve equitable In many cases, will result in
prognosis (eg, the same standard and the most efficient use of outcomes between groups high priority for the sickest
SOFA score, therefore ensures resources to minimise because of the unequal patients; but will exclude the
clinical frailty, co-
consistency. population mortality and distribution of health status very sickest patients who fall
morbidities)
morbidity. amongst the population, including below a threshold where there
Need to ensure that
disparities according to ethnicity, is minimal chance of survival
disability status and age
disability and socioeconomic to ICU discharge (or one year
are not used as proxies
status. after discharge).
for capacity to benefit
and that QALY
assessments are
excluded.
Randomisation / Gives everyone an equal Does not ensure the efficient Should achieve relatively Does not prioritise those with
lottery chance. use of resources to maximise equitable outcomes between the most need.
benefit. patients/groups, at least amongst
those who have access to health
care and present for triage
assessment.
P a g e | 18All people are equally Getting the most from the Achieving equity (achieve ‘more’ Prioritising the people most in
Mechanisms
deserving of care resources (population health) equal outcomes) need
Priority for health Does not treat all Supports population health if: May support equitable outcomes May prioritise those in greatest
care and frontline patients’ equally because (1) priority access to if we believe that primary health need if we interpreted need as
workers (eg, it gives priority to some treatment acts as an care and frontline workers are those at greatest risk of harm;
cleaners)
classes of patients based incentive for essential fairly entitled to priority access evidence suggests that health
on their employment frontline workers to continue due to the special burdens they workers and, in some case,
status and perceived to work before infection have carried on behalf of society. frontline workers are at
social utility. and/or (2) means essential significantly increased risk of
frontline workers recover contracting a pandemic
from critical infection and can infection, such as COVID-19.
resume work. (These
assumptions would need to
be tested with empirical
evidence.)
P a g e | 19National Ethics Advisory Committee | Kāhui Matatika o te Motu
Applying the principles
Example 2: Personal
Prioritising the people most in need
protective equipment Because the principle getting the most from the resources in this case is
allocation defined in terms of harm minimisation, this will for the most part align with
prioritising the people most in need. For both principles, we should
prioritise those at greatest risk (both of infection and risk of serve COVID-
Introduction 19 mortality).
COVID-19 is an easily transmissible infectious disease. Personal
‘Need’ can relate to several distinct criteria. In the case of PPE, these
protective equipment (PPE) is an important component, but only one
include: the need to reduce the chance of contracting infection by those
part, of a system protecting staff and other patients from cross‐infection
who take greater risks because of their health care or other roles; the
of easily transmissible infectious diseases and can be considered a harm
need to protect those who are most likely to contract COVID-19 through
reduction resource since appropriate use significantly reduces risk of
contact with carers; the need to preserve the welfare of those who are
viral transmission.
most affected by COVID-19 (eg, those who are dying and their families).
During a pandemic, PPE must be prioritised and allocated based on
Another option is to prioritise populations that are particularly impacted
proportionate and reasoned guidelines. Overuse of PPE is a form of
by COVID-19.
misuse and should be avoided.
Getting the most from the resources
Distribution of PPE should minimise infection rates of COVID-19 (and
other pathogens) in order to reduce mortality and morbidity from COVID-
19 (and other diseases) across the population.
P a g e | 20This takes account of the risk of exposure and the risk of infection Applied to PPE, social worth would require assessment not of how many
resulting in severe COVID-19 morbidity or mortality. Some groups may lives a clinician could save, but of the instrumental value of that clinician
be at high risk of exposure but low risk of severe COVID-19 or vice versa. in providing patient care, both during and after the pandemic.
Risk of harm to providers contracting COVID-19 within the health care Social worth is not typically an acceptable criterion for distributing health
system will vary according to: care resources and should be invoked only if absolutely necessary and
justified in limited circumstances.
the nature of the clinical encounter, that is, intubation is more
dangerous that transporting patients
Achieving equity
the infectious status of the patient, that is, the patient has confirmed,
Equity requires that distribution of PPE be prioritised to protect
suspected or does not have COVID-19
marginalised groups and prevent or improve inequality around the risk of
other patient characteristics, for example, they are agitated or
contracting COVID-19 or of suffering from a severe COVID-19 infection.
violent
This can be achieved by recognising epistemic authority, that is, listening
other health provider characteristics, for example, comorbidities or to marginalised groups regarding what they need and how best to
age. distribute resources – they have valuable and specialist knowledge about
their own needs.
When distributing limited PPE to clinicians during a pandemic, an
egalitarian approach that treats all clinical roles as equal may not serve Examples include, working with iwi and Māori health groups to ensure
the principle of getting the most from the resources. the needs of Māori are met and Māori are involved in or control
distribution within their communities.
‘Social worth’ is an interpretation of this principle that may be ethically
justified in the unique setting of a pandemic. Similarly, it is important to work with consumer and interest groups, for
example the Disabled Persons Assembly NZ (DPA), to ensure disabled
This recommendation arose from the recognition that some members of
people are not left behind.
society are critical to a successful response to a pandemic.
P a g e | 21You can also read
